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DEPRESSIONAGS Geriatric Evaluation and Management Tools (Geriatrics E&M Tools) support clinicians and systems that are caring for older adults with common geriatric conditions.
n Minor depression: 15% of older peoplen Major depression: 6%–10% of older adults in primary care clinics; 12%–20% of nursing home residents;
n Bipolar disorder: Common among aged psychiatric patients; does not “burn out” in old agen Suicide:
n Older age associated with increasing risk of suicide
n One fourth of all suicides occur in people > 65 years
n Risk factors: depression, physical illness, living alone, white male, alcoholism
n Violent suicides (eg, firearms, hanging) are more common than nonviolent methods among older adults,
despite the potential for drug overdosing
n Not useful for assessing treatment response n 9-item Patient Health Questionnaire (PHQ-9)
n 9 items cover diagnostic criteria for major depression
n Initial 2 questions can be used for screening
n Serial administrations may assess response to treatment
n Not reliable in patients with moderate to severe dementia
If not currently treated, rescreen in 2 weeks. If
currently treated, optimize antidepressant
Start antidepressant therapy; obtain psychiatric
consultation if suicidality or psychosis
n Side effects of drugs for other illnesses may be confused with depressive symptoms
n Medical illness can mimic depression: thyroid disease, conditions that promote apathy, fatigue,
diminished appetite, disturbed sleepn Dementia has overlapping symptoms: impaired concentration, loss of interest, apathy, psychomotor
retardation; sleep disturbancen Bereavement: most disturbing symptoms resolve in 2 months; no marked functional impairmentn Bipolar disorder:
n Elevated, irritable, or expansive mood persisting for at least 1 week, plus 3 of the following: inflated
self-esteem, grandiosity; hypersexuality; marked increase in activity; markedly decreased need for sleep;
pressured speech; racing thoughts, flight of ideas; distractibility
n Grandiose or paranoid delusions may be present
n Older patients are more likely to have an admixture of depression that presents as irritability
n Refer to a psychiatrist due to frequency of recurrence, psychosis, and suicidalityn Psychotic depression:
n Patients have sustained paranoid, guilty, or somatic delusions
n Among older patients, most commonly seen in those needing inpatient psychiatric care
n In primary care, may be seen when patients exhibit unwarranted suspicions, somatic symptoms, or
n Inquire about DSM-IV diagnostic criteria for major depression
n Five or more of the following symptoms have been present during the same 2-week period and
represent a change from previous functioning and at least one of the symptoms is either depressed mood or anhedonia: depressed mood; anhedonia; insomnia or hypersomnia; appetite
changes or unintentional weight changes; psychomotor agitation or retardation; loss of energy; feelings
of worthlessness or guilt; difficulty concentrating or making decisions; recurrent thoughts of suicide or
n Diagnosis in older patients is difficult because they often report somatic symptoms and less often
report depressed mood; they may present with “masked” depression with preoccupation with physical
n Acute phase: Patient begins taking antidepressants to achieve remission of depressive symptoms
n Continuation phase: Once remission of symptoms is achieved, patient remains on antidepressants at
therapeutic doses for an additional 6 months to maintain symptom-free state (prevent relapse)
n Maintenance phase: Patient remains on antidepressants at therapeutic doses to prevent future
recurrence of depression. The duration of maintenance therapy should be based on the frequency and
severity of previous depressive episodes and may need to be lifelong. Maintenance treatment (>3 years) is
provided to patients with bipolar disorders or a history of depression complicated by psychosis, suicidality,
First-line therapy: Selective serotonergic reuptake inhibitors(SSRIs)
n Side effects: anxiety, agitation, nausea and diarrhea, sexual effects, pseudo-parkinsonism, increases
warfarin effect, other drug interactions, hyponatremia/syndrome of inappropriate antidiuretic hormone
secretion; falls and fractures in nursing home residents
Second-line therapy: bupropion (150–300 mg/day)
n Increases activity of dopamine/norepinephrinen Generally safe, well toleratedn Side effects: insomnia, anxiety, tremor, myoclonus; associated with 0.4% risk of seizures
Second-line therapy: venlafaxine (75–300 mg/day)
n Acts as SSRI at low doses; at higher doses, as SNRI n Effective for major depression and generalized anxietyn Side effects: nausea, hypertension, sexual dysfunction
Second-line therapy: duloxetine (20–60 mg/day)
n Equally SSRI and SNRIn Effective for major depression and FDA-approved for neuropathic painn Precautions: drug interactions, chronic liver disease, alcoholism, serum transaminase elevation
Second-line therapy: mirtazapine (15–45 mg at night)
n Norepinephrine, 5-HT2, and 5-HT3 antagonistn May be used for patients with depression and dementia, nighttime agitation, weight lossn Side effects: weight gain, increased appetiten Soluble tablet that dissolves in the mouth (not sublingual)
Monoamine oxidase inhibitors
n Use if patient is resistant to other antidepressantsn Side effects: orthostatic hypotension, fallsn Life-threatening hypertensive crisis if taken with tyramine-rich foods, cold remedies n Fatal serotonin syndrome possible if taken with SSRI, meperidine
Tricyclic antidepressants
n Nortriptyline and desipramine most appropriate for older patientsn For severe depression with melancholic features; avoid if patient has conduction disturbance, heart
disease, intolerance to anticholinergic side effects
n Only 50% of patients with major depressive disorder fully respond to initial treatment
n Another 1/3 recover with antidepressant switch, addition of a second antidepressant, or psychotherapyn
Of those who recover, 40%–60% experience recurrence, depending on severity of first episode and
n Most common prescribing error is not reaching the recommended dose in first 2 weeksn For nonresponse or intolerance, switch to another SSRI or another drug classn For partial response to an SSRI, add bupropion or buspirone
n Effective for treatment of major depression and mania
CONVULSIVE n First-line treatment if patient is at serious risk of suicide, or for life-threatening refusal of food, fluids, THERAPY (ECT)
medicationsn Standard for psychotic depression in older adults; response rate 80% n Anterograde amnesia improves rapidly after treatmentn Retrograde amnesia is more persistent; may lose total recall of events prior to treatmentn Lasting effects not shown in longitudinal studiesn Right unilateral treatment: fewer side effects but less effective than bilateraln Contraindications:
n Recent myocardial infarction or stroke and unstable coronary artery disease increase risk of
complicationsn Continue pharmacotherapy following completion of ECT treatmentn May use maintenance ECT to prevent relapse
Sources: Pacala JT, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 7th ed. New York, NY: American Geriatrics Society; 2010;
and GRS Teaching Slides Web site http://www.frycomm.com/ags/teachingslides.
Copyright 2012 by the American Geriatrics Society.

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